Purpose
The purpose of this page is to educate clinicians on the assessment of frailty syndrome, some of the psychosocial implications of the condition, and what sort of interventions may be most appropriate to address or prevent its onset.
Objectives
1) Understand some of the common accepted assessment measures of frailty and pre-frailty
2) Discuss the association between frailty and depression
3) Discuss physical therapy interventions protocols and dietary considerations
Information about Frailty and Pre-frailty
The Cardiovascular Health Study index (also referred to as the Fried Index), considers the presence of the combination of three of the following traits to be classified as frailty: weight loss of > or = 5% of body weight in the last year, weakness (measured by grip strength), gait speed greater than 6-7s/15 ft, and decreased physical activity as measured in kilocalories per week (M<383, F<270). Pre-frailty considered having 2 of these traits, and robust is marked as having none of them. 1 For single test usage in the clinic, gait speed is considered a reliable measure with good population predictive value of positive outcomes. 2
There is an accepted association between depression and frailty, thought the causality is not known. Both conditions share traits such as disruptions in sleep cycles, and common biomarkers such as hypothalamic-pituitary-adrenal hormone changes. The combined effects of frailty and depression demonstrate a particularly increased risk of mortality in women. Health promotion has been shown to increase quality of life and decrease depressive symptoms in frail patients. Psychosocial needs must be addressed, but it must also be noted that anti-depressant users with depressive symptoms are at increased risk for becoming frail. 3
While large scale studies are lacking, the literature indicates that the safe and proven effective means of improving muscle health at any age is through physical exercise and adequate protein intake. It is thought that it is more vital for these two elements to work synergistically for more development in older people than for younger people (4), and it has been shown that a 24 week program in protein supplementation combined with resistance training increased muscle mass, strength and performance in a frail population. (4, 5)
Suggestions for Exercise Prescription
An exercise prescription advocated by Bray, et al, suggested pre-frail older adults should exercise 2-3 times per week for 45-60 minutes, and that exercise should emphasize resistance and balance, but also include aerobic and flexibility. Frail individuals should exercise 3 times a week for 30-45 minutes with an emphasis on aerobic training. Both sets should work within an RPE of 3-4 on a Borg CR-10 scale. 6
1)Chen MA. Frailty and cardiovascular disease: potential role of gait speed in surgical risk stratification in older adults. Journal of Geriatric Cardiology : JGC. 2015;12(1):44-56. doi:10.11909/j.issn.1671-5411.2015.01.006. 2)Afilalo, Jonathan et al. “Frailty Assessment in the Cardiovascular Care of Older Adults.” Journal of the American College of Cardiology 63.8 (2014): 747–762. PMC. Web. 27 May 2017. 3) Buigues C, Padilla-Sanchez C, Garrido J, Navarro-Martinez R, Ruiz-Ros V, Cauli O. The relationship between depression and frailty syndrome: a systematic review. Aging & Mental Health [serial online]. September 2015;19(9):762-772 Available from: CINAHL Complete, Ipswich, MA. Accessed May 27, 2017. 4) Martone A, Marzetti E, Landi F, et al. Exercise and Protein Intake: A Synergistic Approach against Sarcopenia. Biomed Research International [serial online]. March 21, 2017;:1-7. Available from: CINAHL Complete, Ipswich, MA. Accessed May 27, 2017. 5)M. Tieland, M. L. Dirks, N. van der Zwaluw et al., “Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: a ran- domized, double-blind, placebo-controlled trial,” Journal of the American Medical Directors Association, vol. 13, no. 8, pp. 713– 719, 2012. 6)Bray, N. W., Smart, R. R., Jakobi, J. M., & Jones, G. R. (2016). Exercise prescription to reverse frailty.Applied Physiology, Nutrition, and Metabolism = Physiologie Appliquee, Nutrition Et Metabolisme, 41(10), 1112-1116.
The purpose of this page is to educate clinicians on the assessment of frailty syndrome, some of the psychosocial implications of the condition, and what sort of interventions may be most appropriate to address or prevent its onset.
Objectives
1) Understand some of the common accepted assessment measures of frailty and pre-frailty
2) Discuss the association between frailty and depression
3) Discuss physical therapy interventions protocols and dietary considerations
Information about Frailty and Pre-frailty
The Cardiovascular Health Study index (also referred to as the Fried Index), considers the presence of the combination of three of the following traits to be classified as frailty: weight loss of > or = 5% of body weight in the last year, weakness (measured by grip strength), gait speed greater than 6-7s/15 ft, and decreased physical activity as measured in kilocalories per week (M<383, F<270). Pre-frailty considered having 2 of these traits, and robust is marked as having none of them. 1 For single test usage in the clinic, gait speed is considered a reliable measure with good population predictive value of positive outcomes. 2
There is an accepted association between depression and frailty, thought the causality is not known. Both conditions share traits such as disruptions in sleep cycles, and common biomarkers such as hypothalamic-pituitary-adrenal hormone changes. The combined effects of frailty and depression demonstrate a particularly increased risk of mortality in women. Health promotion has been shown to increase quality of life and decrease depressive symptoms in frail patients. Psychosocial needs must be addressed, but it must also be noted that anti-depressant users with depressive symptoms are at increased risk for becoming frail. 3
While large scale studies are lacking, the literature indicates that the safe and proven effective means of improving muscle health at any age is through physical exercise and adequate protein intake. It is thought that it is more vital for these two elements to work synergistically for more development in older people than for younger people (4), and it has been shown that a 24 week program in protein supplementation combined with resistance training increased muscle mass, strength and performance in a frail population. (4, 5)
Suggestions for Exercise Prescription
An exercise prescription advocated by Bray, et al, suggested pre-frail older adults should exercise 2-3 times per week for 45-60 minutes, and that exercise should emphasize resistance and balance, but also include aerobic and flexibility. Frail individuals should exercise 3 times a week for 30-45 minutes with an emphasis on aerobic training. Both sets should work within an RPE of 3-4 on a Borg CR-10 scale. 6
Additional Resources
1) Diagnostic tools for frailty, and general information website: http://frailty.net/diagnostic-tools/
2) Otago home-based exercise program for strength and balance: http://www.acc.co.nz/PRD_EXT_CSMP/groups/external_providers/documents/publications_promotion/prd_ctrb118334.pdf
3) Nutritional Perspective on frailty:
http://www.todaysdietitian.com/newarchives/090114p52.shtml
4) Resources for care of frailty with other comorbities: http://pathclinic.ca/resources/
5) APA Depression and Suicide in Older Adults Resource Guide: http://www.apa.org/pi/aging/resources/guides/depression.aspx
References
1) Chen MA. Frailty and cardiovascular disease: potential role of gait speed in surgical risk stratification in older adults. Journal of Geriatric Cardiology : JGC. 2015;12(1):44-56. doi:10.11909/j.issn.1671-5411.2015.01.006.
2) Afilalo, Jonathan et al. “Frailty Assessment in the Cardiovascular Care of Older Adults.” Journal of the American College of Cardiology 63.8 (2014): 747–762. PMC. Web. 27 May 2017.
3) Buigues C, Padilla-Sanchez C, Garrido J, Navarro-Martinez R, Ruiz-Ros V, Cauli O. The relationship between depression and frailty syndrome: a systematic review. Aging & Mental Health [serial online]. September 2015;19(9):762-772 Available from: CINAHL Complete, Ipswich, MA. Accessed May 27, 2017.
4) Martone A, Marzetti E, Landi F, et al. Exercise and Protein Intake: A Synergistic Approach against Sarcopenia. Biomed Research International [serial online]. March 21, 2017;:1-7. Available from: CINAHL Complete, Ipswich, MA. Accessed May 27, 2017.
5) M. Tieland, M. L. Dirks, N. van der Zwaluw et al., “Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: a ran- domized, double-blind, placebo-controlled trial,” Journal of the American Medical Directors Association, vol. 13, no. 8, pp. 713– 719, 2012.
6) Bray, N. W., Smart, R. R., Jakobi, J. M., & Jones, G. R. (2016). Exercise prescription to reverse frailty. Applied Physiology, Nutrition, and Metabolism = Physiologie Appliquee, Nutrition Et Metabolisme, 41(10), 1112-1116.